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Training Verbal Working Memory in Children with Mild Intellectual

Disabilities: Effects on Problem-solving

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DOI: 10.5093/psed2018a12

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 ARTICLE IN PRESS
Psicología Educativa (2018) xx(xx) xx-xx

Vol. 00, No 0, Enero 2018

ISSN: 1135-755X

Psicología Educativa
Psicología Educativa
Revista de los Psicólogos de la Educación

Director/Editor
José Antonio León

Subdirectores/Associate Editors
Inmaculada Escudero Domínguez
Robert F. Loarch, Jr.
José Antonio Luengo Latorre
Pamela Maras
Manuel Maretín-Loeches
María José Navas
Rosario Ortega Ruiz
Fernando Sánchez-Sánchez
Paul van den Broek
Lieven Verschaffel

h t t p : / / j o u r n a l s. c o p m a d r i d. o r g / p s e d Educational Psychology
A Journal for Educational Psychologist

Training Verbal Working Memory in Children with Mild Intellectual Disabilities:

Effects on Problem-solving
Margherita Orsolinia, Sergio Melognoa, Teresa Gloria Scalisia, Nausica Latinia, Simona Cairab,
Alessandro Martinib, and Francesca Federicoa
a
Sapienza Università di Roma, Italy; bCentro Ricerca e Cura (CRC) Balbuzie, Roma, Italy

ARTICLE INFO A B S T R A C T

Article history: This multiple case study explores the effects of a cognitive training program in children with mild to borderline intellec-
Received 1 September 2017 tual disability. Experimental training effects were evaluated comparing pre-/post-test changes of (a) a baseline phase
Accepted 16 March 2018 versus a training phase in the same participant, (b) an experimental training versus either a no intervention phase or a
Available online 18 July 2018
control training in two pairs of children matched for cognitive profile. Key elements of the training program included (1)
exercises and card games targeting inhibition, switching, and verbal working memory, (2) guided practice emphasizing
Keywords: concrete strategies to engage in exercises, and (3) a variable amount of adult support. The results show that both verbal
Intellectual disability working memory analyzed with the listening span test and problem-solving tested with the Raven’s Matrices were signi-
Verbal working memory training ficantly enhanced after the experimental training.

El entrenamiento de la memoria de trabajo verbal en niños con discapacidad

intelectual leve: sus efectos en la resolución de problemas

R E S U M E N

Palabras clave:
Este estudio de caso múltiple explora los efectos de un programa de entrenamiento cognitivo en niños con discapacidad
Incapacidad intelectual
intelectual entre leve y límite. Se evaluaron los efectos de entrenamiento experimental comparándose los cambios pre/
Formación en memoria de
trabajo verbal posprueba de (a) una fase basal frente a una fase de entrenamiento en el mismo participante y (b) un entrenamiento
experimental frente a una fase sin intervención o un entrenamiento de control en dos pares de niños emparejados en el
perfil cognoscitivo. Los elementos clave del programa de entrenamiento constaban de: (1) ejercicios y juegos de cartas
cuyo objetivo es la atención, inhibición, conmutación y memoria de trabajo verbal, (2) práctica guiada enfatizando estra-
tegias para realizar ejercicios y (3) un grado variable de apoyo por parte del adulto. Los resultados demuestran que tanto
la memoria de trabajo verbal analizada mediante la prueba de capacidad de escucha como la resolución de problemas
medida a través de las Matrices de Raven mejoraron significativamente después del entrenamiento experimental.

Working-memory has a central role in complex learning as it between them. Working memory is involved in learning something
allows the simultaneous storage and manipulation of information. To new (Cowan, 2014), when logical or semantic connections between
learn a rule, for instance, individuals have to recall examples and keep different elements still have to be established. Before associations
them in a temporary memory store to develop an abstract schema are formed between the parts of a new procedure or a new concept,
or rule from them (Anderson, Fincham, & Douglass, 1997). Learning working memory is particularly taxed.
complex concepts also challenges working memory as one must keep According to an influential multi-component model (Baddeley,
active in mind the relationship between other dependent concepts. 2000, 2010; Baddeley & Hitch, 1974), working memory consists
To build the concept of “son-in-law”, for example, you have to keep of a central executive whose limited attentional control capacity
active in mind the concepts of daughter’s husband and daughter’s is responsible for the active maintenance and processing of task-
parents and, at the same time, conceptualize the relationship relevant information, which is temporarily held in domain-specific

Cite this article as: Orsolini, M., Melogno, S., Scalisi, T. G., Latini, N., Caira, S., Martini, A., & Federico, F. (2018). Training verbal working memory in children with mild intellectual
disabilities: Effects on problem-solving. Psicología Educativa. Advance online publication. https://doi.org/10.5093/psed2018a12

Funding: This research is part of the project “Memoria di lavoro e processi di ragionamento in bambini con sviluppo tipico e con deficit cognitivi” [Working memory and reasoning
in children with typical development or intellectual disabilities] which has been funded by Sapienza University of Rome (contract number: RP116154BDC8E008). Correspondence:
[email protected] (M. Orsolini).

ISSN: 1135-755X/© 2018 Colegio Oficial de Psicólogos de Madrid. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 ARTICLE IN PRESS
2 M. Orsolini et al. / Psicología Educativa (2018) xx(xx) xx-xx

verbal and visuospatial stores or a multi-modal episodic buffer control group. Training effects on verbal working memory were not
(Baddeley, 2000). The description of the central executive as a cluster explored in this study.
of executive functions whose specific control process consists of Van der Molen, Van Luit, Van der Molen, Klugkist, and Jongmans
updating the contents of working memory, switching between (2010) used a dual task in which children were asked to process
different tasks or procedures, inhibiting irrelevant information or the current stimuli (e.g., identifying which figure is the odd one),
actions, and coordinating multiple tasks is consistent with this model and remember a target item (e.g., recalling a target location across
(Baddeley, 1996; Miyake & Friedman, 2012). increasingly longer spans). A large group of adolescents with mild-to-
An increasing number of studies have examined the effects of borderline intellectual disabilities participated in either an adaptive
working memory training but research exploring whether executive or a stable training regimen with the visual dual task; a control group
functions and working memory can be effectively enhanced in was trained with a single task. Results showed that children trained
children with mild to borderline intellectual disability (ID) has been with dual tasks (no matter whether adaptive or stable) improved
relatively scarce. This type of clinical population, however, would their visual WM only at follow-up testing, whereas performance with
particularly benefit from evidence-based interventions targeting verbal WM was not affected by training in any testing phase. The
these cognitive functions. authors also found transfer effects on arithmetic and story recall at
In fact, it is well known that children with ID have lower follow-up, but no transfer effects on performance with the Raven’s
performance than chronological age comparisons in most tests Matrices.
assessing executive functions (Alloway, 2010; Danielsson, Henry, Söderqvist, Nutley, Ottersen, Grill, and Klingberg (2012) analyzed
Messer, & Rönnberg, 2012; Levén, Lixell, Andersson, Danielsson, the effects of a training procedure combining WM and non-verbal
& Rönnberg, 2008). Behavioral inhibition and interference control reasoning (NVR) tasks. A sample of forty-one children with ID
are particularly impaired in this population (Bexkens, Ruzzano, participated in two training groups that used the same NVR tasks but
Collotd’Escury-Koenings, Van der Molen, & Huizinga, 2014). Studies differed regarding their treatment with either adaptive or non-adaptive,
analyzing performance in working memory tasks in children with computerized, visual, simple-span tasks. There was large individual
ID show heterogeneous domain specific effects (Van der Molen, Van variability in children’s responses to intervention, and only children
Luit, Jongmans, & Van der Molen, 2007) that are related to disorder- who made remarkable progress in the training tasks showed improved
specific impairments (Jarrold, Baddeley, & Hewes, 1999; Jarrold, performance in verbal or visual working memory at post-testing. This
Purser, & Brock, 2006; Lanfranchi, Cornoldi, & Vianello, 2004). study shows that progress in verbal WM after training can occur in
However, there is evidence that working memory (WM), particularly children with ID but with highly variable individual differences.
in the verbal domain, is weaker compared to mental age peers in Bennett, Holmes, and Buckley (2013) used a computerized WM
most children with ID (Jarrold, Baddeley, & Hewes, 2000; Schuchardt, training consisting of visuospatial simple and complex span tasks.
Gebhardt & Maehler, 2010; Schuchardt, Maehler & Hasselhorn, 2011; Children with Down syndrome (DS) aged seven to twelve years
Van der Molen, Van Luit, Jongmans, & Van der Molen, 2009) and even were allocated to either the intervention program or a waiting list
in children with borderline intellectual functioning (Hasselhorn & group. Children in the intervention group significantly improved for
Maehler, 2007; Henry, 2001; Henry & MacLean, 2002). visuospatial WM both immediately after the training and at four-
The weak development of working memory and difficulties month follow-up but the training showed no effects on verbal WM.
with attentional shift (Vakil & Lifshitz-Zehavi, 2012) contribute Parent ratings of behavior also showed that after training there was
to a range of other cognitive deficits in this developmental clinical a highly significant reduction in difficulty with shifting behaviors for
population. First, problem-solving processes tend to be less effective children in the intervention group.
if not supported by working memory. Henry and MacLean (2003), Danielsson, Zottarel, Palmqvist, and Lanfranchi (2015) performed
focusing on the relation between analogical reasoning and the a training group minus control group analysis in a meta-analytic
different components of WM, found that measures tapping the review and concluded that only mixed WM training, with both verbal
central executive were the most significant predictors of arithmetic and visuo-spatial components, showed significant training effects in
reasoning for participants with ID. Second, poor verbal working studies involving children with ID. An analysis of the training effects
memory is likely to have detrimental effects on those processes in distinguishing verbal and visuo-spatial short-term memory (STM)
which language can support concepts and skills acquisition, from and WM showed larger effect sizes for the STM tests.
following instructions (Gathercole, Durling, Evans, Jeffcock, & Stone, In summary, most studies involving children with ID used
2008) to lexical-semantic acquisition (Baddeley, 2003). Third, there computerized training of visual or visuo-spatial WM (see also Pulina,
is a strong association between working memory and executive Carretti, Lanfranchi, & Mammarella, 2015). Such training seems to
functions on one hand and academic learning on the other hand in generate remarkable enhancements especially in visual working
children with intellectual disabilities (ID) and borderline intellectual memory though the effects tend to be medium-small in terms of
functioning (Henry & Winfield, 2010; Numminen et al., 2000; effect size (Danielsson et al., 2015). Effects on verbal working memory
Poloczek, Büttner, & Hasselhorn, 2012). Even externalizing behavior – as assessed by dual tasks asking both processing and memorization
problems seem to be associated to impaired working memory in of verbal stimuli – are rare (but see Costa, Purser, & Passolunghi,
these children (Schuiringa, van Nieuwenhuijzen, Orobio de Castro, & 2015; Orsolini, Melogno, Latini, Penge & Conforti, 2015; Söderqvist
Matthys, 2017). et al., 2012). Transfer effects of WM training to academic learning or
Although such correlational data suggest that executive functions everyday functioning are also rare (but see Bennett et al., 2013 and
and working memory should be a preferential target of cognitive Van der Molen et al., 2010 ) whereas transfer to problem-solving and
training methods for children with mild to borderline ID, the reasoning are not documented for children with ID.
questions of whether such functions can be effectively enhanced and Thus we are at an early stage of research on the effects of working
whether other cognitive functions or learning processes can improve memory training programs for children with intellectual disabilities
as an indirect effect of WM training are still open. and there is a need for group studies to identify the training conditions
Moalli, Rota Negroni, and Vianello (2004) explored the effects of that are more suited to this clinical population. On the other hand,
a training method focused on both teaching concepts on memory involving children with cognitive deficits in training programs that do
functioning and practicing specific mnemonic strategies with verbal not target academic skills cannot answer yet parents’ and educators’
and visuospatial tasks. Improvements from pre- to post-treatment concern that such programs may take time away from more
in verbal short-term memory and visuo-spatial WM occurred in evidence-based instructional practices. Case studies may therefore
children with Down syndrome (DS) when they were compared to a be particularly useful in such a phase to collect preliminary evidence
 ARTICLE IN PRESS
Training Verbal Working Memory 3

that the time spent in working memory training can be beneficial to stimulating attention, inhibition, switching, and verbal working
other cognitive processes, such as inference and reasoning skills. memory; 2) guided practice emphasizing strategies to engage in
In line with this preliminary research objective, our multiple case exercises (e.g., verbalization to promote the task’s goal maintenance);
study explores whether verbal working memory can be enhanced by 3) adapting the adult’s degree of support to the task difficulty and the
training in children with a mild to borderline intellectual disability child’s level of performance; and 4) sessions starting with an initial
of a non-specific etiology who have a history of language delay. It conversation and going on with one adult’s led exercise presented
also analyzes whether training verbal working memory generates a through PowerPoint and one card game (see examples in Table 2).
transfer effect to problem-solving and cognitive flexibility. Attention. As illustrated in Table 2, our experimental training
started from attention, as attention is involved in working memory
Method (Vandierendonck, 2014), and it is known that weak attention skills
are often present in children with ID, with a strong negative impact
Participants on working memory (Kirk, Gray, Riby, & Cornish, 2015). Activities
in this unit asked the child to identify parts of incomplete pictures,
After approval from the Ethics Committee of the Department name elements of complex scenes that were shown on the computer
of Developmental and Social Psychology (Sapienza University screen for a limited amount of time, and describe features in order to
of Rome), an informed consent was asked to the parents who support a character’s identification for the other player.
accepted to have their children involved in this study. Participants
Inhibition. Activities stimulating inhibition of a dominant
were children whose mild intellectual disability (IQ between 55
response asked participants to process affirmative and negative
and 70) or borderline intellectual functioning (IQ between 71 and
sentences to accomplish selection of target items (e.g., “The thief
85) had been diagnosed by a certified clinical psychologist within
wears a red tie”, “The thief does not have blond hair”) or lexical-
public clinics in the area of Rome who tested them with the WISC-
semantic categorization of pictures (e.g., the child is shown four
III (Wechsler, 1991) and assessed their adaptive functioning. The
pictures on the computer screen and is asked to quickly name the
children had shown wide learning disabilities since their first grade
class and were assisted by a special educator who, according to only picture belonging to a target category for some slides and then
the Italian law, helps the children with special needs for a varying to name the only picture not belonging to a target category for other
amount of time (accordingly to the severity of their impairment) slides).
within regular classes. Children were selected by either a Switching and simple verbal working-memory tasks. Activities
psychologist within the public clinic in which the diagnosis had in this unit asked participants to practice different actions in the same
been issued or the child’s special educator. The following selection exercise (e.g., looking at the picture and either saying something that
criteria were used: (a) the child had some type of language delay was not true for that picture or saying something that was true but
(see Table 1) and the psychologist or the child’s special educator different from the word that was written on the top of the picture).
judged that he/she could benefit from a training targeting verbal Simple verbal working-memory tasks asked participants to recall
memory, (b) the child’s parents had communicated an intention to sequences of items and accomplish, at the same time, a selection
involve the child in a therapy and were deemed to be motivated of items according to a target semantic category or other target
to support their child’s engagement in the training, and (c) the characteristics.
psychologist or the child’s special educator judged the child to be Complex working memory tasks. Participants were asked either
motivated to participate at new learning experiences. to recall information after having accomplished a different task (e.g.,
recalling a sentence after having judged whether that sentence was
The Experimental Training friendly or not) or to accomplish inferences (e.g., guessing the place
in which a short dialogue has occurred) after the content of a short
Key elements in our program included (1) specific activities passage had been listened to and encoded in episodic memory.

Table 1. Participants’ Characteristics1 and Methods of Analyzing the Training Effects

Participants
Ilaria (female) Simone (male) Roberta (female) Lucrezia (female) Dino (male)
Methods of analyzing the training Baseline versus training Training versus waiting list Experimental versus control training
effects versus follow-up assessment
after interruption
Age (years, months) 10, 6 10, 3 9, 6 12, 3 12, 1
IQ (WISC III)1 70 70 70 75 72
Language difficulties Low lexical comprehension Phonological delay1 Phonological delay1 Slow lexical access Phonological delay1
(IQ = 72 )1 (word finding
Deficit in verbal Low verbal short- difficulties)1
Low verbal short-term short-term memory term memory (z =
memory (z = -1 in a word (z = -2.3 in a word -1 in a word span Low verbal short- Low verbal short-
span test)2 span test)2 test2) term memory (z = term memory (z
-1.3 in a word span = -1.66 in a word
test)2 span test)2
Diagnosis Mild Intellectual disability Mild Intellectual Mild Intellectual Borderline Borderline
disability disability intellectual intellectual
functioning functioning
Setting of the training Home School University clinical center
1
Characteristics reported in this table are drawn from the reports of the participants’ assessment in the clinical center that issued the original diagnosis and are based either on
standardized tests (e.g. Lexical comprehension was assessed through the Italian adaptation of the Peabody Picture Vocabulary Test, Dunn & Dunn, 1981) or clinical observations
made by the psychologists and speech therapists involved in the original diagnosis.
2
The word span test is the initial condition of the Word Interference test (Nepsy II; Korkman et al., 2007).
 ARTICLE IN PRESS
4 M. Orsolini et al. / Psicología Educativa (2018) xx(xx) xx-xx

Table 2. The Experimental Training Stimulating Verbal Working Memory

Switching and simple verbal Complex working memory

Attention Inhibition working memory
Adult’s led Verbalization of stimuli Maintenance of the task’s goal Rehearsal strategies
interaction Systematic visual exploration Divided attention Task planning and sequencing
is focused on Sustained attention Selection of members of target Focus on relevant information
enhancing… Selective attention categories. Summarizing the available information
Anticipation of possible sources of difficulty
Generalization of approach to different tasks
Examples of · Animal detective: An · Characters detective: A · Guessing what: The · Stories: Short narrative
computer- incomplete picture appears thief has been seen from participant is asked to discover sequences are read by the
presented on the computer screen people who describe his/ what the object hidden on the adult and are also shown on
exercises and and quickly disappears. her characteristics. Relying computer screen is by relying the computer screen with the
card games The participant is asked to on each of such descriptions on the information provided written text accompanied
recognize the animal and then (e.g., “the thief was not a by two types of characters. by a picture. For instance: “A
identify the lacking part of the woman” or, “the thief did not A wizard will say something hare was very proud of herself
picture, selecting it from four wear glasses”), the participant that is opposite of the real because she could run quickly.
cards. removes images from a pool characteristic (e.g., “if the One day she said to all the
· Monsters: Therapist and child of suspects until the thief is wizard says that the thing other animals: - Nobody is
take turns in selecting one or identified. is put on a lower part of the quicker than me; nobody has
more cards with monsters, · Category: Each player has six body, you have to think that it the courage to race with me-”.
describing their characteristics cards and proceeds on a game is put on an upper part of the After the last sentence is read,
and communicating the of the goose board if he/she body”). A pessimistic man will the short passage disappears
precise location in which they can play cards according to say something true but will from the computer screen,
put them. If the second player the category specified on the add pessimistic evaluations and the participant is asked to
(who cannot see what the board box. Categories may be that may distract you (e.g., produce a pragmatic judgment
first is doing) makes the same single or multiple (e.g., “food “he will say that you wear this (e.g., “is what the hare says
choices as his/her companion and furniture”) and affirmative thing when it is hot, and he friendly?”) and then to recall
does, the first player wins or negative (e.g., “no fruits, no will add that if you do not do the sentence.
some points. clothes”). so, it may be very dangerous, · Take cards and remember:
and you can even die”). Each player has three picture
· The dolphin game: Players cards and can take one of four
proceed with a game of the picture cards on the table,
goose if they can repeat the following the given rules (e.g.,
sequence of words that has humans can take animals,
being said by the other player animals can take plants or
and add a new word according fruits, plants or fruits can take
to the instruction specified on objects). At the end of the
the board box. Boxes on the round, each player attempts
board ask for a fixed number to recall the word that was
of words (from 2 to 6) either written on each of the taken
starting with a given letter or cards (e.g., the word “surprise”
belonging to a given category. written under the image of a
birthday cake), and if he/she
manages to do so, he/she wins
the cards.

The Control Training working memory was trained with a software (Mammarella, Toso, &
Caviola, 2010) targeting first immediate attention and memory of visual
Control training targeted narrative memory and visuo-spatial stimuli and then active memory involving dual tasks of maintaining and
working memory. Narrative memory was trained with both conversation processing information. This software considers two aspects of visuo-
and structured activities (see Table 3) asking the participant to recall spatial WM: the nature of the stimulus (visual, spatial-sequential, and
personal events, verbally reconstructing the plot of a short video clip, spatial-simultaneous) and the level of attentional control, with tasks
imagining fictional events to link pictures in card games. Visuo-spatial demanding a low, medium or high level of control.

Table 3. Activities Stimulating Narrative Memory in the Control Training

Conversation The participant was asked to verbally share personal events and the therapist also produced personal narratives. The
therapist used questions to support narrative expansion soliciting the child’s recalling of events, acknowledged the
participants evaluations, and occasionally rephrased or synthesized the child’s utterances.
Recalling video clips The therapist and the child looked at a video clip showing one episode from popular cartoons. At the end the child was
asked to image that the video transformed in a picture book: “what would show the first picture?” No matter whether the
answer of the child described the starting event or a subsequent one, the therapist showed a printed picture depicting the
event described by the child and solicited some semantic elaboration. The therapist’s subsequent questions asked the child
to recall “what happened then?” and again used printed pictures to enrich the child’s recalling of events.
Sentences linking different images The child can use card pictures and language cards. A specific verb phrase is selected from language cards (e.g. ___ realizes
and verb phrases that ____) and the child is asked to produce a sentence with that verb phrase including one or more card pictures. There are
also special language cards with connectives such as “when”, “because”, “if”, “and at the end” that can be used to build a
longer sentence. The therapist and the child take turns in producing sentences and compete for producing the longest but
“coherent” sentence.
The Goose game The gameboard has pictures depicting fictional characters, actions, objects. Each player can proceed on the board if
manages to link the events described by the previous player to the one depicted in the picture where he/she landed after
throwing the dice.
 ARTICLE IN PRESS
Training Verbal Working Memory 5

Similarly to the experimental training, each session started with analyzing pre-/post-test changes after either a baseline phase in
conversation to promote a close adult-child relationship and build a Ilaria or a waiting list phase in Roberta. The experimental training
practice of sharing personal memories. After such a warming stage, effects were evaluated through three types of comparison:
there were exercises with the software stimulating visuo-spatial analyzing pre-/post-test changes after (a) a baseline versus an
working memory followed by structured narrative activities. experimental training phase in Ilaria, (b) an experimental training
versus a no intervention phase in Simone and Roberta, (and c) an
Experimental Design experimental training versus a control training in Lucrezia and
Dino. We could replicate an experimental effect three times across
Case studies have to specify the conditions under which their different participants, in line with one basic criterion recommended
results could be replicated (Wolery & Ezell, 1993). To understand by Horner et al. (2005) for single-case designs.
whether the training could be effective regardless of the setting in
which is delivered, we choose to involve the participants in a training Dependent Measures and Materials
that took place either at the child’s home (Ilaria) or at school (Simone),
or at a university clinical center (Lucrezia). The participants’ pre-/post-test changes were analyzed assessing
Studies exploring whether participants’ performance can improve attention, executive functions of inhibition and switching, verbal
after cognitive training have to rule out that increasing exposure short-term memory, verbal working memory, problem-solving, and
to tests, or unspecific factors, such as increased motivation, are cognitive flexibility.
the crucial conditions generating changes. To understand whether Attention. Selective and sustained visual attention was evaluated
participants’ improvements from pre- to post-training assessment with the Bells Test (Biancardi & Stoppa, 1997), in which the participant
could be interpreted as generated by the training itself, we choose must cancel 35 pseudo randomized bells found on a horizontal sheet
three types of comparison, as shown in Figure 1. The first participant, of paper mixed with another 315 figures. The bells are located in
Ilaria, was involved in a within-subject design by comparing the seven columns, three in the right visual field, three on the left, and
effects of a baseline condition with those of the experimental one in the centers. As the participant’s task is to locate the bells and
training, and then with those of a training interruption (see Figure 1). cross them out in the shortest possible time, and to repeat the search
Each phase of baseline, training, and interruption consisted of eight across four sheets, we used two main scores: the number of bells
weeks and was preceded and followed by testing. crossed in the first 30 seconds of each of the four sheets and the total
number of bells crossed in the 120 seconds allowed for each of the
four sheets. The first score is likely to involve selective attention; the
Assessment Assessment Assessment second score taps the participant’s capability of sustaining attention
effectively to the same visual search target.
Ilaria Ilaria Ilaria Inhibition and switching. In this timed test of the Nepsy
Home II battery (Korkman, Kirk, & Kemp, 2007), the ability to inhibit
Baseline Comparing Experimental Interruption
the effects training automatic responses in favor of novel responses and the ability to
8 weeks 8 weeks 8 weeks switch between response types is assessed. In the Naming phase of
the task, the participant looks at a series of black and white shapes
Roberta School Simone (circle and square) or arrows (pointing up and down) and names
Comparing either the shape or the direction. In the Inhibition phase, the child
Waiting list Experimental
the effects training The training names the same symbols but is asked to apply the non-target label
8 weeks occurred in
8 weeks three different (e.g., saying “square” for a circle or “up” for an arrow pointing down).
contexts for In the Switching phase, the child is asked to say the correct name
Dino two weekly
University lab Lucrezia sessions of for black symbols but to apply the non-target label if the symbol is
Control Comparing Experimental two-hours white (e.g., “down” for a white arrow pointing up or “circle” for a
training the effects training each over
eight weeks white square). The completion time and the total number of mistakes
8 weeks 8 weeks
(including self-corrections) are evaluated for naming, inhibition and
Figure 1. The Research Design.
switching.
Verbal short-term memory. A Forward digit span (Gugliotta,
Bisiacchi, Cendron, Tressoldi, & Vio, 2009), in which the examiner
A second participant, Simone, was involved in a between-subject reads a list of numbers – a digit per second – and the participant must
design and participated at the experimental training taking place immediately repeat them back, was used to evaluate verbal short-
at school and lasting eight weeks. Simone’s pre-/post-training term memory. The starting point in the task is a three-digit list, and
improvements were compared with those of Roberta who was the span is increased until the participant fails in all three lists of the
assessed before and after eight weeks of a “waiting list” phase. same span. The score is the highest span in which the child manages
Simone and Roberta were selected in the same school, attended to correctly repeat two out of three lists of that span. Verbal short-
the same grade IV class, and showed a similar cognitive profile (see term memory was also tested with a word span using the first part of
Simone versus Roberta in Figure 1). the Word Interference test from the Nepsy II. The child is presented
In order to further examine training effects and distinguish them in an auditory manner with blocks of words increasing in span (from
from either test familiarity effects or generic effects introduced by two to five) and is asked to repeat them in the same order. The
motivation, we involved a third participant, Lucrezia, in a between- number of blocks correctly repeated is the task score.
subject design and compared her pre-/post- experimental training Although the experimental training did not target verbal-
improvements to the pre-/post-control training changes observed in short term memory with specific activities, exploring whether
Dino. Lucrezia and Dino were selected in the same University clinical some changes are induced in such function will allow us to better
center and showed a similar cognitive profile (see Lucrezia versus understand the underlying nature of verbal working memory
Dino in Table 1 and Figure 1). improvements, clarifying whether they are related to a more effective
Thus our study can evaluate both test familiarity and training primary memory for verbal information or a stronger central
effects. Tests’ familiarity effects were analyzed in two ways: executive enabling children to cope with dual tasks in the verbal
 ARTICLE IN PRESS
6 M. Orsolini et al. / Psicología Educativa (2018) xx(xx) xx-xx

domain. Cognitive flexibility. The Animal Sorting test from the Nepsy II
Verbal working memory. Verbal working memory was assessed (Korkman et al., 2007) was used to assess concept formation and the
with both a simple and a complex dual task. The simple task, ability to flexibly shift from one concept to another. The child sorts
Backward digit span (Gugliotta et al., 2009), is similar to a Forward pictures cards as quickly as possible into two groups of four cards
digit span in the presentation of the items and score assignment, each, using self-initiated criteria. The score is the number of correct
but at the end of each sequence, the participant is asked to recall the different categories in which the participant sorts the pictures cards.
presented digits in the reverse order. The complex dual task is the
Listening span test, an Italian adaptation (Pazzaglia, Palladino, & De
Procedure
Beni, 2000) of the Daneman and Carpenter’s (1980) task consisting of
sentences that are auditorily presented in blocks of increasing span
The children’s parents were interviewed by a therapist who
(from two to six). The participant is asked (i) to judge the plausibility
illustrated the treatment and made explicit that it would target “basic
of each sentence (state whether it is true or false) and (ii) to recall the
abilities” – such as verbal working memory or narrative memory –
last word of each sentence, in the correct order, at the end of each
rather than academic skills. At the end of the interview parents
block. The total number of words correctly recalled in order provides
signed an informed consent.
one type of score. For instance, if a subject is presented with a six-
span block and recalls the last word of the third and fourth sentences Therapists were 5th year developmental psychology students
in the right order, the score in this block would be 2. Further types undertaking an intensive training course in which they could
of score are the number of errors with sentence judgements and follow the guiding principles of each type of experimental and
the number of intrusion errors. Intrusion errors consist of recalling control training activity and practice simulations of adult-child
words that do not occupy the sentence ending position (e.g., recalling verbal interaction. Therapists were supervised by the first author
“football” instead of “mountain” for the sentence Football is a sport on a regular basis and there was a checklist asking them to report
that you can only practice in a high mountain), and a high number of observations on the child´s performance in each training session.
intrusion errors is an indicator of difficulties in inhibiting irrelevant Each training activity had written instructions which therapists were
information. instructed to follow.
Problem-solving. The Raven’s Colored Matrices (Raven, Court, & In the baseline phase of Ilaria (see Figure 1) the therapist visited
Raven, 1992) were used with the primary school participants and the the participant at home and engaged for eight weeks in two weekly
Standard Progressive Matrices (Raven, 1989) consisting of 60 items sessions of one hour play and conversation with the objective of
were administered to the two 12-year-old children. building an adult-child warm relationship. This was followed by an

Table 4. Difference in Standard Scores Between Post- and Pre- assessments

Visual attention Executive attention

Verbal short-term Verbal working Problem- Cognitive
Selective Sustained memory memory solving flexibility
Inhibition Switching
attention attention
Combined Combined Forward Forward Backward Listening Raven’s Animal
score score Digit Span Word Span Digit Span Span Test Matrices Sorting
Difference post/
pre-test after
1.55& 0.46& 0 -0.33 0& 0.66 0.90& 0 0.49 0.33&
the baseline
condition
Difference post/
pre-test after the
0.41 0.11 0.67 1.00*^ 0 0.66 0 2.17**^ 1.50*^ 0.66
experimental
training
Ilaria
Difference post/
pre-test in the 0.40 0.21 0 0.66 0 0 0 0 0.39 0.33
follow-up

Difference post/
pre-test after the
0 0.11 1.00* -0.66 0.48 1.66* 0.50& 1.88*^ 1.43* 1.66*
Simone experimental
training
Difference post/
pre-test after
-0.03 0.47 2.00**^ 1.66** 0 0 0.05& -0.62 1.48* 0
Roberta the waiting list
period
Difference post/
pre-test after the
2.09^ 3.12^ 1.33*^ 1.00* -0.85& 0 0& 1.18**^ 1.53*& 0.66&
Lucrezia experimental
training
Difference post/
pre-test after the 1.52 2.00 -2.00 & 0.33 0 0 0.90& 0.51 0.40 2.33**^
Dino
control training
Standard scores preceded by a minus sign mean that the post-test standard score was lower than the pre-test one.
*Standard scores with a reliable change index of 1.96 or greater and that equate to 95% confidence interval.
**Standard scores with a reliable change index of 2.58 or greater and that equate to 99% confidence interval.
^Standard scores changed from being below the mean (i.e., -1 or lower) in the pre-test to be within the normal limits in the post-test (i.e., -0.7 or higher)
&
Standard scores were within the normal limits in the pre-test
 ARTICLE IN PRESS
Training Verbal Working Memory 7

experimental training phase of eight weeks consisting of two weekly error of the difference takes into account the test standard deviation
sessions of two-hours each, in which the child was engaged with (SD) and the test reliability (rel), as follows: SD*sqrt(2)*sqrt(1-
the experimental training activities. Then there was an interruption rel). Only if the RCI is 1.96 or greater the difference is statistically
phase of eight weeks that coincided with the summer vacations and significant (1.96 or 2.58 equates to the 95% or 99% confidence interval
was followed by a follow-up assessment. The person who tested respectively). Following Norup et al. (2017), we also distinguished
Ilaria was the same person who met her once a week in the baseline between post-test scores showing only a reliable change and those
condition and was then involved as a therapist in the experimental scores that changed from being outside the normal limits in the pre-
training (N.L., the fourth author). test to be within normal limits in the post-test. We will refer to such
Simone was involved in a school-based experimental training type of scores as “clinically significant change”. Such change would
consisting of two weekly sessions of two-hours each over eight suggest that a training is effective in supporting an internal process
weeks that took place in a primary school laboratory. In the first of learning and development bringing specific behavioral parameters
weekly session the child was involved with computer-presented within the normal range.
training exercises (see Table 2) and interacted individually with a
therapist. In the second weekly session Simone was involved with
the card games of the training and interacted with another child with Results and Discussion
learning disabilities along with the therapist. Simone’s pre-/post-test
We converted each raw score into a standard score, considering
changes were compared to those of Roberta, who participated at a
“waiting list”. The two children were assessed before and after either the chronological age norms of each test. The difference in standard
the training or the “waiting list” phase by the same person, who was score between the post- and the pre-training assessment of each
not involved in Simone’s training. test was then computed, as shown in Table 4. Marked with one or
Lucrezia and Dino were involved in the experimental and control two asterisks are the scores showing statistically significant reliable
training respectively that took place in a University clinical center and change index. We will refer to such scores as “reliable” changes,
were delivered by the same therapist. Both experimental and control meaning that the difference post-/pre-test is not “just statistical
training consisted of two individual two-hour weekly sessions over noise resulting from the lack of the perfect reliability of the chosen
eight weeks, in which the child interacted with the therapist in a assessment instruments” (Norup et al., 2017).
room at the center. The two participants were assessed before and To compute the standard error of the difference between the
after training by the same person (N.L.) who had not been involved post- and the pre-test scores the tests’ reliability was considered
in their treatment. by selecting it from the English manual of the Nepsy II (Korkman
“Near” and “far” transfer training effects. The first issue et al., 2007). For the Raven’s Matrices we considered the minimum
explored by our study is whether there are “near transfer effects” reliability of .80 emerging from Carlson and Jensen (1981). For the
of the experimental training, asking whether specific cognitive listening span test we considered the reliability reported in Pazzaglia
functions (i.e., executive functions of inhibition and switching, verbal et al. (2000). Reliability of the attention test was not available and the
WM) that have been directly stimulated by the training improve in significance of the pre-/post-test difference could not be computed
the post-treatment assessment. The tests assessing such cognitive for this test.
functions consist of tasks quite different from the training activities. Marked with “^” in Table 4 are the pre-/post-test scores that
For instance, verbal working memory was assessed through two not only show a reliable change but also improved from being
tests: backward digits recall and the listening span test. There was no outside the normal limits in the pre-test to be within normal limits
training activity asking participants to implement the manipulations in the post-test. We will refer to such type of scores as “clinically
required by these two tests (e.g., recalling items in a reverse order significant change”.
or recalling in the correct order the last word of sentences that have
been first judged true or false). As tests and training activities consist
“Near” Transfer Effects
of different tasks, this allowed us to assess a true transfer effect. As the
tests’ tasks involved the cognitive functions that have been directly
Table 4 shows the results on selective and sustained attention:
stimulated by the training, near transfer effects can be detected.
out of the four children who could receive the effects of either
Our second issue was whether the experimental training had
experimental (Ilaria after the training, Simone, Lucrezia) or control
transfer effects for other than trained cognitive functions. Whereas
training (Dino), only two (Lucrezia and Dino) showed a marked
the experimental training stimulated central executive attention,
improvement. It is clear that the experimental training did not induce
working memory, and inferential processes in the verbal domain,
specific effects on attention, at least when such function is assessed
we assessed problem-solving and concept formation in the visual
through a visual search task.
domain, through Raven’s Matrices and a cognitive flexibility test
(Animal Sorting from the Nepsy II; Korkman et al., 2007), respectively. Focusing on executive attention, we considered for Inhibition and
Selecting tests in a domain that was not specifically stimulated by Switching the standard scores that combine errors and completion
the training allowed us to evaluate the transfer potentiality of the time (combined scaled scores). Test familiarity effects occurred for
experimental training. Roberta who remarkably improved for Inhibition; for Switching she
Analyzing reliable pre-/post-test changes. To analyze a training changed from being unable to pass the familiarization phase in the
effect we have to ask if a participant’s improvement from pre- to post- pre-test to get a score corresponding to 1 standard deviation below the
test is significant or is just a variation stemming from the imperfect mean in the post-test. We attributed to Roberta’s initial assessment
reliability of the chosen test. The reliable change index method (RCI; of Switching the same pre-test score she showed for Inhibition and
see Bauer, Lambert, & Nielsen, 2004; Jacobson & Truax, 1991; Norup, thus her pre-/post-test difference turned out to be a reliable change.
Spangsberg Kristensen, Poulsen, & Mortensen, 2017) was used to Test familiarity effects, that could have been observed in two children
determine the statistical significance of change with eight-week test- (Ilaria after the baseline, Roberta after the waiting list period) were
retest interval that occurred either for a baseline, a waiting list, or a only observed in Roberta, whereas experimental training effects
training phase. RCI allows you to determine who has changed reliably occurred for three out of three children (Ilaria after the training,
and is calculated as (X2−X1)/Sdiff, where X1 and X2 are the individual’s Simone and Lucrezia). Dino, who was involved in the control training,
observed scores in the pre- and post-test, and Sdiff is the standard did not show any improvement with executive functions of Inhibition
error of the difference between the two test scores. The standard and/or Switching.
 ARTICLE IN PRESS
8 M. Orsolini et al. / Psicología Educativa (2018) xx(xx) xx-xx

Table 5. Participants’ Performance in the Listening Span Test Analyzed with Standard and Raw Scores

Listening span test

Number of words correctly Number of errors in judging

Number of intrusion errors
recalled in sequence sentences plausibility

Initial assessment -1.09 (raw score:11) -0.7 (raw score: 2)   -0.12 (raw score: 1)
After the baseline condition -1.09 (raw score: 11) -0.7 (raw score: 2)   -0.6 (raw score: 0)
Ilaria
After the experimental training 1.08 (raw score: 20) -0.01 (raw score: 1)   -0.12 (raw score: 1)
Follow-up assessment 1.08 (raw score: 20) -0.01 (raw score: 1)   -0.12 (raw score: 1)

Initial assessment -2.22 (raw score: 5) 1.7 (raw score: 3) 4.62 (raw score: 10)
Simone
After the experimental training -0.34 (raw score: 14) 1.7 (raw score: 3) 1.03 (raw score: 3)

Initial assessment -1.39 (raw score: 9) -0.05 (raw score: 1) 1.03 (raw score: 3)
Roberta
After the waiting list period -2.01 (raw score: 6) 1.7 (raw score: 3) 3.6 (raw score: 8)

Initial assessment -1.77 (raw score: 15) 0.89 (raw score: 4) 3.14 (raw score: 5)
Lucrezia
After the experimental training -0.59 (raw score: 22) 0.10 (raw score: 2) 1.63 (raw score: 3)
Initial assessment -2.78 (raw score: 9) 0.10 (raw score: 2) 3.89 (raw score: 6)
Dino
After the control training -2.27 (raw score: 12) -0.29 (raw score: 1) 7.65 (raw score: 11)

Interpreting the Findings concerning Focusing on Dino, who was involved in a control training targeting
Verbal Working Memory both visuospatial working memory and verbal recalling with
narrative memory tasks, it was observed that his performance with
Assessing verbal working memory with backward digits span the listening span test did not improve. This suggests that simply
failed to show reliable training or test familiarity changes in the practicing the recall of verbal information from long-term memory
participants. Conversely, when verbal working memory was or being trained with dual tasks in a non-verbal domain may not be
assessed with the listening span test robust training effects were effective to enhance verbal working memory.
observed. None of the three participants who could show either If participants’ improved performance with the listening span
test familiarity (Ilaria after the baseline, Roberta after the waiting test involves a strengthened working memory, how can we explain
list period) or control training effects (Dino) showed a reliable or the lack of improvements in performance with the backward digits
clinically significant improvement in the listening span test. On the span? To answer such a question we should emphasize that words
contrary, each of the three children involved with our experimental memorization may depend on cumulative rehearsal in the listening
training (Ilaria, Simone, and Lucrezia) showed a reliable and span test. The participant encodes in memory the last word in
clinically significant change. In other words, each child started a sentence after having judged the semantic plausibility of such
with a dysfunctional performance in the listening span test’s initial sentence; this process is repeated for the subsequent sentences and
assessment and then reached a score within the normal range word traces in memory can be strengthen by a cumulative rehearsal
in the post-training assessment (see Table 5). In the follow up (e.g., silently repeating the first and second memorized word before
assessment Ilaria maintained the improved performance with the attending to the third sentence). In the backward digits span the
listening span test. participant has to first keep in memory a sequence of digits and then
There were two types of evidence suggesting that the participants’ recalling them in a reverse order. The effectiveness of processing the
improvements involved working memory. First, the ability to recall digits’ order reversal is a function of the sequence of items that is kept
more words in sequence in the listening span test did not occur at in the short-term memory store. As the short-term store has not been
the cost of a less effective sentence processing. As shown in Table 5, strengthened in our participants, manipulating digits in a reverse
in which raw and standard scores for performance in the listening order did not undergo any improvement. Another factor explaining
span test are reported for each participant, there was no increase of the different results of backward digits span and the listening span
errors in sentence judgements in the children who improved after the test may be that the participants’ pre-test scores were much lower for
experimental training. An enhanced ability to control interference the latter and that our training program could more easily improve
when recalling words was also observed (see a decrease of intrusion lower scores.
errors in Ilaria after the training, Simone, and Lucrezia). These
findings suggest that after the experimental training children were “Far” Transfer Effects
more skilled in implementing the dual task of judging the semantic
plausibility of the current sentence and keeping in memory the last Focusing on problem-solving, out of two children who could
word of the previous sentences. show test familiarity effects (Ilaria after the baseline, Roberta after
A second type of evidence clarifying the underlying nature the waiting list period), only Roberta made a reliable change in
of children’s improvement with the listening span test was the performance with the Raven’s Matrices. Conversely, each of the three
participants’ stable ability to store a sequence of words or digits in children involved with the experimental training made a reliable
short-term memory. As verbal short-term memory did not increase change in performance with the Raven’s Matrices (but only two
after the experimental training, as shown in Table 4 (only Simone of them had a post-test score within the normal limits). Concept
showed a reliable change in the words span test), this suggests formation, on the other hand, showed a reliable change in Simone
that the improved performance in the listening span test was not and a clinically significant improvement in Dino, who was involved
generated by an enhanced capacity of the short-term verbal store. with the control training.
In other words, children were not more skilled in memorizing words Thus despite the fact that the experimental training stimulated
but more able to direct attentional resources towards the two parallel working memory and inferential processes through activities in
goals of judging the plausibility of each sentence and memorizing the the verbal domain, each of the three children involved with the
sentence’s last word. experimental training showed reliable changes in performance with
 ARTICLE IN PRESS
Training Verbal Working Memory 9

the Raven’s Matrices. This finding suggests that our experimental complex training – in which variation largely prevailed on repetition
training allowed participants to address a problem-solving task in the and strategies co-occurred with practicing exercises – succeeded in
visual domain with higher attention control and better monitoring of significantly improving verbal working memory. Three children with
ongoing procedures. mild to borderline intellectual disabilities who initially had an impaired
performance with the listening span test, after eight weeks of training
Test Familiarity versus Training Effects showed a performance within the normal limits in the same test.
We were interested in exploring whether training working memory
We represented in Figure 2 the number of scores whose change in could allow children to implement problem-solving in the visual domain
the post-test was “reliable”. We focused on those 6 tests that allowed in a more effective way even if this had not been directly stimulated
us to compute a reliable change index and identify near and far by training. We did find that an enhancement of problem-solving with
transfer training effects. If test familiarity was to explain a substantial the Raven’s Matrices was more likely after the experimental training
part of participants’ changes in the post-test we should expect than our control conditions. We were not interested in distinguishing
such influence to underlie in a rather similar way each participant. whether children’s improvement in problem-solving was related to
However, the trend suggested by the findings illustrated by Figure 2 is a more strategic approach to the task (e.g., better visual scanning of
different: out of the 15 reliably significant increments in the post-test, all the items before selecting a solution), or a strenghtened capacity
11 are shown by the three children assessed after the experimental to construct visuo-spatial relations. For this reason we avoided the
training and 4 by the three children assessed after either baseline, or phrase “fluid intelligence” in reference to performance with the Raven’s
a waiting list phase, or the control training. We ran the Fischer’s Exact Matrices and preferred to interpret children’s higher scores in this task
test on the data reported in Table 6 and found that differences were as indicators of an increased capacity to coordinate cognitive processes
statistically significant (two-tailed p-value = .0234). to address a problem-solving task.
Thus, finding that the children observed in this study could
substantially enhance their performance with the Raven’s Matrices
Number of scores that showed a reliable change in the post-test suggests that training working memory might be a preliminary step
Number of scores that did not show a reliable change in the post-test to enhance complex cognitive processes. A tentative conclusion of
7
this study is that skills-based interventions involving coordination
6 between task-relevant cognitive processes (Kearns & Fuchs, 2013)
might be more effective if prepared by preliminary working memory
5
training. Instruction focusing strategies for understanding or writing
4 texts, solving mathematical problems, and building novel concepts is
3 likely to be facilitated in children with mild intellectual disabilities if
their verbal working memory has been enhanced.
2

1 Limitations
0
Ilaria after Ilaria after Simone after Roberta after Lucrezia after Dino after The conclusions of this study are based on a very small number of
baseline experimental experimental waiting list experimental control training children and should obviously be contextualized taking into account
training training phase training
the specific characteristics of participants. First, children involved in
this study had a history of language difficulties that was not associated
Figure 2. Number of Scores that Showed or did not Show a Reliable Change in to a severe short-term memory deficit. Thus the conditions that limit
the Post-test.
verbal working memory malleability remain to be identified in future
case studies. Second, participants were selected in this study because
Table 6. Data for the Fisher’s Exact Test they were deemed to be motivated to participate at training and their
engagement could also be supported by their parents’ motivation.
Number of scores
observed after the Number of scores Motivation, along with beliefs about the nature of intelligence,
baseline, waiting observed after the seems to affect the degree of transfer to reasoning skills in individuals
phase and the control experimental training involved in working memory training (Jaeggi, Buschkuehl, Shah, &
training
Jonides, 2014). Thus an overt assessment of motivation and beliefs
Reliable change in the about learning and intelligence should be included in future research.
4 11
post-test
A further limitation is that we assessed retention of training effects
Non-reliable change in
14 7 after a phase of training interruption only in one case (Ilaria). It
the post-test
remains to be explored whether enhanced verbal working memory
and problem-solving are long-term training effects. Eventually, the
Conclusions training transfer effects could have been even larger than those found
in our study if training had stimulated both verbal and visual working
In this exploratory multiple case study, working memory was memory, as suggested by some meta-analysis studies (Danielsson et
trained along with executive functions of inhibition and switching. al., 2015; Schwaighofer, Fischer, & Bühner, 2015).
The training method consisted of several different tasks which
stimulated participants’ control of attention, capacity of alternating Conflict of Interest
different procedures, and ability of implementing complex processing
(e.g., semantic categorization, pragmatic judgments, inferences) on The authors of this article declare no conflict of interest.
memorized verbal information. The use of language as a “tool” to
orient attention to task materials, focus and recall instructions, and
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